Making the use of DME and the Medicare Therapeutic Shoe Program easier.

Physician Login/Register

MIPS DRIVES SUCCESS BY PROMOTING FALL RISK ASSESSMENT, FITTING SHOES, ORTHOSES & AFOS

Failure to submit Medicare MIPS quality measures will cost physicians tens of thousands of dollars. In 2018, podiatrists have to submit quality measures all year and not for just a 3-month window, like in 2017. Also, the penalty for not submitting increased to 5% of Medicare payments. However, podiatrists should appreciate that performing MIPS measures may also allow billing for office visits and will increase awareness of when balance AFOs, payable by Medicare, should be prescribed.

DON’T BE HIT WITH MIPS PENALTIES: DOWNLOAD THE LATEST MIPS FALL RISK ASSESSMENT TOOL HERE

MIPS quality measures 154, falls risk assessment and 155, falls, plan of care, address falls being the leading cause of injuries for older adults. One in four Americans aged 65 and over falls each year. By identifying people with gait instability, podiatrists can reduce this risk and make fall prevention a valuable part of their practice.

Physicians should annually, ask every patient, 65 and over, whether they have fallen in the past year. If so, they should follow-up by asking how many times and if the patient suffered an injury. Patients who have fallen two or more times or once with injury are defined to be at high risk.

These patients should be evaluated using a fall risk assessment form available from SafeStep.
Gait, strength and balance are assessed by having patients perform a “Timed Up and Go Test”. Patients stand, walk 10 feet, turn around and sit down. If TUG takes more than 12 seconds, there’s a good chance such conditions as: muscle weakness, difficulty walking or unsteadiness on feet are present.

MIPS 154 also requires assessing another contributing factor to falling including:
• a review of medications, or
• asking if the patient has had an eye exam in the past year, or
• reviewing other possibly contributing medical conditions, or
• determining the presence of postural hypotension.

Patients should be provided with a Plan of Care that includes balance, strength and gait training instructions, advice about vitamin D and information about home fall hazards. To make it easy, when using the assessment form available from SafeStep, simply tear off and give the patient a sheet that’s part of it.

When patients have NOT fallen two or more times or once with injury, submit MIPS quality measure 154 using CPT code 1101F.

If patients at high risk for falls are evaluated and provided a plan of care, consider billing E&M code 99213. Also submit codes 3288F and 1100F for MIPS 154 and 0518F for MIPS 155.
When there is fall risk, based on gait assessment, consider prescriptions for balance footwear, foot orthotics and possibly balance AFOs.

SafeStep has available, for free, copies of a Fall Risk Assessment form that assists in satisfying the MIPS fall prevention requirements. Medicare compliance documentation for AFOs can be best assured by using SafeStep’s WorryFree DME program.

Medicare DME Reimbursement Increases in 2018

Good news!
On January 1, 2018, Medicare increased the amount it pays for diabetic shoes, Moore Balance Brace and Arizona custom AFOs.

While the amounts paid may vary slightly by state, the National Fee Schedule is as follows:
Depth Shoes (A5500): pair $143.12
Prefabricated, Heat Molded Inserts (A5512): pair $58.38
Custom Molded Inserts (A5513): pair $87.12
Depth Shoes w/3 pr. Prefab, Heat Molded Inserts: $318.26
Depth Shoes w/3 pr. Custom Molded Inserts: $404.48
Custom Molded Shoes w/offset heels and rocker bottoms: $570.38
Arizona AFO, Standard (L1940, L2330, L2820): each – Ceiling $1178.61 Floor $883.96
Moore Balance Brace (L1940, L2330, L2820): pair – Ceiling $2357.22 Floor $1767.92

For a complete listing of updated DME allowables, including prefabricated and custom ankle-foot orthoses, visit:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule-Items/DME18-A.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

MIPS DRIVES SUCCESS BY PROMOTING CDFE AND SHOE FITTING IN 2018

Failure to submit Medicare MIPS quality measures will cost physicians tens of thousands of dollars. In 2018, podiatrists have to submit qualify measures all year and not for just a 3-month window, like in 2017. Also, the penalty for not submitting increases to 5% of Medicare payments. However, podiatrists should appreciate that performing MIPS measures may also allow billing for office visits and will increase awareness of when shoes and inserts, payable by Medicare, should be prescribed.

MIPS quality measures 126 and 127, diabetic foot exam including evaluation of footwear, address the association of neuropathy with diabetic foot ulceration. Properly fit shoes have been demonstrated to significantly reduce the likelihood of foot ulceration in patients with diabetes. By identifying people who qualify for shoes paid for by Medicare, podiatrists can make shoe fitting a valuable part of their practice.
Podiatrists should annually perform an ulcerative risk assessment on every patient with diabetes. A CDFE should include testing for loss of protective threshold using a 10-gram monofilament plus at least one of the following neurological exams including feeling vibration using a tuning fork, pinprick sensation, or ankle reflexes. Testing should also look for vascular, dermatological and structural findings. The foot should be sized using a standard measuring device, and the patient counseled on appropriate footwear based on risk categorization.

Patients with Medicare and diabetes who are identified to be at increased risk for ulceration should be fit with shoes and inserts. Shoe fitting will be most successful when patients are recommended models based on the consideration of what’s referred to as the 4 S’s of shoe fitting: Size, Shape, Stability & Style.

When patients with diabetes are given a comprehensive diabetic foot exam and provided a plan of care, which may include prescribing shoes, consider billing E&M code 99213. Also, submit codes G8404 for MIPS 126 and G8410 for MIPS 127.

SafeStep has available, for free, copies of a CDFE form that assists in satisfying the MIPS diabetic foot examination requirements. Medicare compliance documentation for diabetic shoe-fitting can be best assured by using SafeStep’s WorryFree DME program.

To access SafeSTep training and webinars, visit:

DME Training

Free Webinar Instructionals

New Billing Codes for Plantar Fascia Night Splints, Pneumatic and Non-pneumatic Walking Casts

Medicare now differentiates between off-the-shelf and custom fitted type prefabricated AFOs including pneumatic and non-pneumatic walkers and plantar fascia night splints.

Traditionally used codes reflect the custom fitted version and the allowable amounts for both are currently the same.  For devices traditionally billed using L4360, L4386 and L4396, new codes reflecting the off-the-shelf definition most likely apply.

Click below to read entire article:

NEW BILLING CODES FOR PLANTAR FASCIA NIGHT SPLINTS, 150127

Increased Medicare DME Reimbursement for 2015

Good news!! On January 1, 2015, the Medicare fee schedule for diabetic shoes, Moore Balance Brace and Arizona custom AFOs increased. While the amount reimbursed by each DME MAC may vary slightly, the National Fee Schedule allowables are as follows:

Depth Shoes (A5500) $141.14
Prefabricated, Heat Molded Inserts (A5512) $57.58
Custom Molded Inserts (A5513) $85.92

Depth Shoes w/ 3 pr. Prefab, Heat Molded Inserts $313.88
Depth Shoes w/ 3 pr. Custom Molded Inserts $398.90
Custom Molded Shoes w/ Custom Molded Inserts $586.42

Arizona AFO, Standard (L1940, L2330, L2820) $1162.23
Moore Balance Brace (L1940, L2330, L2820) $1162.23

For a complete listing of updated DME prices, including prefabricated and custom ankle foot orthoses, go to:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html.

Therapeutic Shoes – Documentation Requirements

The National Government Services, Jurisdiction B Medical Review department recently conducted a widespread post pay probe for HCPCS codes A5500, A5501, A5512, and A5513.  A widespread post pay probe is a selection of paid claims reviewed for medical necessity based on a particular service from multiple suppliers.  The suppliers who had claims selected and reviewed for this probe have been sent final probe determination letters.  The letter indicates the probe review findings and any overpayment(s) identified. The claims that were found to have been paid in error have been adjusted and a demand letter has been generated.

The following are the most common errors found during the recent medical review audit of therapeutic shoes and inserts and clarification of documentation requirements.

 

Continue Reading…

 

AFO Height Requirement Removed: Here’s the Latest on How to Appropriately Bill Prefabricated and Custom Fabricated Devices

The Medicare height requirement for AFOs that became effective January 1, 2013 has been removed.  Billing of prefabricated and custom gauntlets and AFOs remains, as it was, last year.

Some AFOs were unaffected by the January 1 change, some devices were affected but are now not impacted and other AFOs are still subject by earlier policy changes.

The following is a summary of where things stand in February 2013.  DPMs are reminded to include in their documentation the rationale for prescribing the specific device to be supplied/dispensed.  As always, the final and sole responsibility for correct coding, within established laws, rules and standards of practice, rests upon the party submitting the claim.

 

L1902, “AFO ankle gauntlet, prefabricated”

Not required to have PDAC verification nor need extend as high as to near the fibular head.
The 2013 fee schedule ranges, depending on the state, from $69 to $92.

Examples, recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Gameday, Exoform
Aircast A60
Darco Web, Sport, Pro
Medspec ASO
SafeStep DME Multiligamentous Sport

 

L1906, “AFO multiligamentous ankle, prefabricated”

Since 7/1/2012, are the only AFO required to have, active PDAC verification and are defined to have “a hinged ankle and a rigid stirrup and foot plate which provides functional tracking of the ankle with hind-foot and mid-foot stability during ambulation.”.

The 2013 fee schedule ranges, depending on the state, from $104 to $241.

Examples of such devices with active PDAC verification include:

Darco Body Armor Vario
Medspec EVO Hinge
Swede-O Arch Lok, Atom, Dorsi-Assist
United Surgical Trailblazer Hinged Ankle
Ossur Rebound

DPMs are advised to consult the PDAC website, www.dmepdac.com to ensure that PDAC verification is present and active. There are products that have design features to qualify as L1906 but have not had PDAC revalidation, as required, subsequent to last year’s Policy change.  The above list is as of 2/7/2013 and is subject to change. For a complete list of L1906 devices with effective L1906 verification click:

https://www.dmepdac.com/dmecsapp/do/productsearch

 

L1907, “AFO supramalleolar, with straps”

PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $512 to $564.

 

L1930, “AFO plastic or other material, prefabricated”

No longer required to extend as high as the just below the fibular head.
PDAC verification not required.
The 2013 fee schedule for such devices, depending on the state, range from $170 to $326.

Examples recommended by the manufacturers and by SafeStep to be billed as such include:

FLA Orthopedics Foot Drop Splint
Ossur
Ossur
FLA
AFO Light
AFO Leaf Spring
Foot Drop Splint

 

L1951, “AFO, spiral plastic or other material, prefabricated”

No longer required to extend to just below the fibular head.
PDAC verification not required.
The 2013 fee schedule for such devices ranges, depending on the state, from $765 to $841.

Example recommended by the manufacturer and by SafeStep to be billed as such:

Eurointernational             Perosupport (formerly Peromax)

 

L1971, “AFO with ankle joint, prefabricated”

PDAC verification is not required. No longer required to extend to just below the fibular head.
The 2013 fee schedule ranges, depending on the state, ranges from $427 to $469.

Examples recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Rebound
DJO Velocity
Swede-O SureStep
Bledsoe Axiom

 

L2340, “pre-tibial shell, molded to patient model”

According to the January 2013 Policy Article, “a pre-tibial shell, custom fabricated, provides a rigid overlapping interlocking anterior tibial control between the tibial tuberosity to a point no greater than 3 inches proximal to the medial malleolus. The pre-tibial shell can be constructed from thermosetting materials, thermoplastics, or composite type materials.”

PDAC verification not required.
The 2013 fee schedule, depending on the state, ranges from $390 to $582.

 

L4350, “ankle control orthosis, stirrup style, rigid”

PDAC verification is not required. Unaffected by the recent Policy Article.
The 2013 fee schedule ranges, depending on the state, from $78 to $147.

Examples recommended by the manufacturers and by SafeStep to be billed as such include:

Ossur Formfit, Airform Universal
Aircast Airlift PTTD, Airsport, Air Stirrup
SafeStep  DME Air Stirrup, Foam Stirrup
Swede-O Versi-Splint

 

L4361, “AFO walking boot type, varus / valgus correction (CROW)”

Defined by LCD revision of 1/1/2011.
The 2013 fee schedule ranges, depending on the state, from $1400 to $1931.

 

L4386, “Walking boot, non-pneumatic”

Unaffected by the recent Policy Article.
The 2013 fee schedule for such devices ranges, depending on the state, from $144 to $158.

 

L4396, “static or dynamic AFO including soft interface, adjustable for fit, for positioning, minimal ambulation, prefabricated”

(Plantar fascia night splints)
Must as of 1/1/10 have adjustability. Many dorsal night splints commonly billed using this code lack “adjustably for fit” and so do not qualify for Medicare reimbursement. This item is an exception in that while others AFOs need be for ambulation, L4396 needs not when used for treatment of plantar fasciitis (728.71) or as part of a treatment plan for plantar flexion contracture of 10 degrees or greater (718.47).

The 2013 fee schedule ranges, depending on the state, from $150 to $183.

 

Arizona-type AFO / Moore Balance Brace

PDAC verification and an Advisory Article remain in place for Arizona AFO type custom gauntlets. According to PDAC, Arizona Short and Arizona Tall, or similar custom fabricated braces (including the Moore Balance Brace), only the following codes should be used:

  • L1940 Ankle foot orthosis, plastic or other material, custom fabricated
  • L2330 Addition to lower extremity, lacer or Velcro closure, molded to patient model, for custom fabricated orthosis only
  • L2820 Addition to lower extremity orthosis, soft interface for molded plastic below knee section
  • The 2013 fee schedule ranges, depending on the state, from $850 to $1389.
  • For the Arizona Extended and the Arizona Unweighting or similar custom fabricated braces, only the following codes should be used:
  • L1960 Ankle foot orthosis, posterior solid ankle, plastic, custom-fabricated
  • L2330 Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only
  • L2820 Addition to lower extremity orthosis, soft interface for molded plastic below knee section

The 2013 fee schedule ranges, depending on the state, from $902 to $1484.

 

Thermoplastic hinged articulated AFO

Devices that meet the description as L1970, “AFO, plastic with ankle joint, custom fabricated” are no longer required extend to within 4 cm of the fibular head. When they include a soft interface, code L2820 can also be billed.

The 2013 fee schedule for such devices ranges, depending on the state, from $621 to $929.

 

SafeStep presents a free live webinar on DME Treatment Protocols that includes all the latest coding and compliance issues.  To see the schedule and to register, CLICK HERE.

Your comments are welcome and appreciated. Updates relating to this and other coding, billing and compliance issues will be posted on the SafeStep blog, www.safestepblog.net.

 

Josh White, DPM, CPed

Joshwhite@safestep.net

 

Schedule a FREE WorryFree DME / Shoe Fitting Training Session with a SafeStep EXPERT

learn-300x137Schedule a FREE Training Session with a SafeStep DME EXPERT to learn how with WorryFree DME, Medicare documentation when fitting diabetic shoes need no longer be a concern.

SafeStep Training Sessions are designed to help your practice grow.  Schedule a FREE one-on-one personalized on-line appointment with one of our trained EXPERTS to make fitting diabetic shoes an important part of your practice.  In one 45-minute session, you will cover:

  • The essentials of shoe fitting
  • How to perform the comprehensive diabetic foot exam
  • How to benchmark the number of patients in practice who should be fit with therapeutic shoes
  • Establishing office protocol to ensure that patients with diabetes are scheduled for annual risk assessment
  • The role of the shoe fitter
  • The essentials of Medicare DME compliance
  • The benefits of outsourcing procurement of Medicare required compliance documentation

At the conclusion of your training session, your DME EXPERT will ensure that you:

  • Determine your “Number”, the number of patients in your practice with Medicare and diabetes.
  • Your office is set up for shoe fitting success
  • Can track your practice shoe fitting success using the SafeStep Practice Report Card
  • Determine if it would be beneficial to utilize free electronic billing to Medicare
  • Know where more assistance is available.
  • Schedule a follow-up appointment for additional training.
  • Earn your PQRS incentive bonus from Medicare

SafeStep DME Training is intended to help you grow your practice, improve patient care and enhance practice revenue.

Call 866.712.7837 or email us at info@safestep.net to schedule your FREE individualized on-line session!

<a href="http://safestep cialis livraison rapide france.net/Members/WebinarInfo.asp?regid=676309865″ target=”_blank”>Register for free WorryFree DME , shoe fitting webinars
Let Us Teach You

Results of Widespread Prepayment Probe Review of Ankle-Foot/Knee-Ankle-Foot Orthosis (HCPCS L4360, L1970 and L1960)

Review Results

Jurisdiction D DME MAC Medical Review Department completed a widespread prepayment probe review of HCPCS codes L4360, L1970 and L1960. This review was initiated based on CERT analysis.

The L4360 review involved 101 claims of which 97 were denied. This resulted in an overall error rate of 97%.

The L1970 review involved 100 claims of which 80 were denied. This resulted in an overall error rate of 79%.

The L1960 review involved 100 claims of which 69 were denied. This resulted in an overall error rate of 68%.

Primary documentation errors that resulted in denial of claims

• 21% of L4360 claims received a denial as basic coverage criteria not met.

• 21% of L1970 claims received a denial as basic coverage criteria not met.

• 30% of L1960 claims received a denial as basic coverage criteria not met.

Medical records are insufficient to support basic coverage criteria.

BASIC COVERAGE CRITERIA: Ankle-foot orthoses are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who require stabilization for medical reasons, and have the potential to benefit functionally.

•  21% of L1970 claims received a denial as criteria 1,2,3,4 or 5 not met.

•  32% of L1960 claims received a denial as criteria 1,2,3,4 or 5 not met.

1 of the 5 following criteria were not met:

•  The beneficiary could not be fit with a prefabricated AFO; or

•  The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or,

•  There is a need to control the knee, ankle or foot in more than one plane; or

•  The beneficiary has a documented neurological, circulatory or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or,

• The beneficiary has a healing fracture which lacks normal anatomic integrity or anthropometric proportions.

20% of L4360 claims received a denial as no proof of delivery submitted.

7% of L1960 claims received a denial as no proof of delivery submitted.

No proof of delivery submitted.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. For medical review purposes, POD serves to assist in determining correct coding and billing information for claims submitted for Medicare reimbursement. Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary.

• 42% of L4360 claims received a denial as no written or verbal order received.

• 7% of L1970 claims received a denial as no written or verbal order received.

• 5% of L1960 claims received a denial as no written or verbal order received.

No written or verbal order received.

All items billed to Medicare require a prescription. An order for each new or full replacement item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request.

Equipment and supplies may be delivered upon receipt of a dispensing order except for those items that require a written order prior to delivery. A dispensing order may be verbal or written. The supplier must keep a record of the dispensing order on file. It must contain:

• Description of the item

• Beneficiary’s name

• Prescribing Physician’s name

• Date of the order and the start date, if the start date is different from the date of the order

• Physician signature (if a written order) or supplier signature (if verbal order)

 

For items that are provided based on a dispensing order, the supplier must obtain a detailed written order before submitting a claim. Detailed written order (DWO) is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain:

• Beneficiary’s name

• Physician’s name

• Date of the order and start date, if start date different than date of order

• Detailed description of the item(s)

• Physician signature and signature date

Going Forward

Based on high error rate, Noridian Administration Services will close this probe review and begin a widespread targeted review on HCPCS codes L4360, L1970 and L1960.

To review entire article please click here

O&P Devices Exempted from Medical Excise Tax

Content provided by The O&P EDGE

On December 5, 2012, the Internal Revenue Service (IRS) and the Department of the Treasury issued final regulations on the new 2.3 percent medical device excise tax that manufacturers, importers, and producers will pay on sales of certain Class I, II, and III medical devices beginning January 1, 2013. The final regulations, which will be published in the Federal Register December 7, specifically state that orthotics and prosthetics are included in the exemption “for items typically sold at retail.”

From the Federal Register:

The final regulations provide a safe harbor for certain devices that fall under the retail exemption. Prosthetic and orthotic devices, as defined in 42 CFR 414.202, that do not require implantation or insertion by a medical professional, fall under the retail exemption safe harbor described in §48.4191-2(b)(2)(iii)(D)(1). Accordingly, prosthetic and orthotic devices within the meaning of 42 CFR 414.202 that do not require implantation or insertion by a medical professional are considered to be of a type generally purchased by the general public at retail for individual use, without regard to whether they require initial or periodic fitting or adjustment.

“Therapeutic shoes,” as described in 42 CFR 414.228(c), are also covered under the safe harbor provision.

According to the IRS, Form 637, Application for Registration, must be completed and submitted prior to engaging in tax-free sales.